Complex Claims Adjuster, Workers Compensation

Pie Insurance

5d•$95,000 - $120,000•Remote

About The Position

Pie's mission is to empower small businesses to thrive by making commercial insurance affordable and as easy as pie. We leverage technology to transform how small businesses buy and experience commercial insurance. Like our small business customers, we are a diverse team of builders, dreamers, and entrepreneurs who are driven by core values and operating principles that guide every decision we make. The Complex Claims Adjuster will play a critical role in delivering quality claim file management and an industry-leading customer claims experience, by providing hands-on adjudication of catastrophic and large loss claims. This will be completed by adhering to Pie’s Claims Best Practices, complying with regulatory and statutory requirements, and applying advanced knowledge and experience with complex negotiation strategies, structured settlements, Medicare Set-Aside requirements, and overall risk evaluation and mitigation. This role will work with internal and external partners to deliver best in class performance, identify and pursue claim mitigation opportunities and deliver favorable claim outcomes for Pie’s customers. Additionally, the Complex Claims Adjuster will collaborate with the Complex Claims Practices Consultant and Claims leadership to continually seek out ways in which to improve claims processes and protocols.

Requirements

High School Diploma or equivalent is required.
Minimum of 7 years workers’ compensation claim adjusting experience is required (carrier background, preferred).
2+ years of catastrophic claim handling experience.
Ability to evaluate and identify high dollar, high exposure, complex claims.
Strong claims handling experience within the Southeast region preferred, with expertise in Florida, Georgia, and/or North Carolina. Candidates should demonstrate a willingness to expand their jurisdictional knowledge and obtain additional state licenses as business needs evolve.
Requires active licensing in applicable states.
Advanced communication (written and verbal) skills, to deliver more complex information effectively.
Advanced problem-solving skills to be able to manage complex tasks and work through to solutions with little guidance and direction.
Awareness of your own tasks and how it impacts the team and deliverables.
Advanced knowledge of jurisdictional regulatory and statutory requirements and CMS/MSA requirements.
Advanced knowledge and experience in claim adjudication, medical, and litigation management.
Advanced ability to analyze and take necessary action in multiple focus areas based on several data points.
Ability to make claim decisions to mitigate exposure while achieving the best outcome.
Ability to use skills to overcome conflict and reach beneficial outcomes.
Ability to mentor junior adjusters.

Nice To Haves

Bachelor's Degree or equivalent experience with some college coursework is preferred.
Experience using G-Suite Tools and collaboration tools like Slack is preferred.

Responsibilities

Independently handle all aspects of catastrophic and large loss workers’ compensation claims from set-up to closure.
Conduct timely 3-point contact investigation, with focus on continued investigation as facts of the case change.
Determine timely and accurate compensability decisions within statutory requirements.
Set and adjust timely/accurate reserves within authority limits to ensure reserving activities are consistent with the case facts and company best practices.
Ability to present claims to senior management, internal and external stakeholders.
Timely administration of statutory medical and indemnity benefits throughout the life of the claim.
Comply with all applicable statutory guidelines, rules, and regulations.
Control legal activity with defense counsel through the litigation process while managing legal fees and costs.
Prioritize early resolution opportunities, evaluate claim exposure and negotiate settlement.
Mitigate the complex exposure while achieving the best outcome.
Serve as a point of contact for our partner agents and customers to provide general claim guidance and help set claim process expectations.
Provide claim status to agents and insureds, coverage verification and loss run reports, etc as necessary.
Provide excellent customer service to internal/ external customers and business partners.
Work to continuously improve our claims operations and address opportunities and gaps in claim service, handling SOPs, protocols and processes.
Direct a proactive litigation strategy to increase settlement opportunities.
Assess claims for settlement value using rated ages, present value, medicare set asides, medical cost projections and structured settlements. Obtain settlement authority as required.
Obtain annuity and structured settlement quotes.
Attend virtual and in person mediations, informal settlement conferences and trials to represent Pie's interests.
Participate in Claims Roundtable meetings. Develop a collaborative plan of action for aggressive claims handling.
Create Claims Status Reports and establish timely, accurate reserves.
Present large loss updates to internal and external partners.
Collaborate with our Complex Claims Practices Consultant and Claims Leadership to continuously improve our claims operations and look at opportunities and gaps in claim service, handling SOPs, protocols and processes.